Module 2 - Alterations in Fluids and Electrolytes Flashcards

1
Q

Every disease process involves some alteration in ..

A

fluids and electrolytes

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2
Q

Molecule

A

When two or more atoms combine to form a substance

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3
Q

Ion

A

an atom carries an electrical charge because it has either gained or lost electrons

some ions have a negative charge and some positive charge

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4
Q

Cation

A

Ion that carries a positive charge and it has given away or lost electrons

Positive charge

fewer electrons than protons

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5
Q

Anion

A

an ion that has gained electrons and therefore carries a negative charge

negative charge

gained or taken on electrons (more electrons than protons)

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6
Q

In health there is ___ amounts of cations and anions in the body

A

equal

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7
Q

Electrolytes

A

substance dissolved in solution and some of its molecules split or dissociate into electrically charged atoms or ions

critical for life and muscle function

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8
Q

What is the unit of measurement for volume of fluids ?

A

metric - L or mL

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9
Q

In the body, non-dry areas are in ___

A

solution

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10
Q

The unit of measure that expresses the combining activity of an electrolyte is …

A

the milliequivalent (mEq)

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11
Q

One mEq of any cation will …

A

always react chemically with one mEq of an anion

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12
Q

What information does mEq’s provide?

A

information about the number of cations or anions available to combine with other cations or anions

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13
Q

The fluid in each of the body compartments contains …

A

a particular composition of electrolytes which differ from that of other compartments

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14
Q

To function normally, body cells must have …

A

the right amount of fluids and electrolytes (and being in the right compartments)

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15
Q

Whenever an electrolytes moves out of a cell..

A

another electrolyte moves in to take its place

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16
Q

Homeostasis

A

a state that requires the number of cations and anions to be the same in order to exist

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17
Q

Body compartments are separated by..

A

semi permeable membranes

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18
Q

Intracellular Compartments

A

Fluids inside the cells

Most of the body fluid (2/3) is inside the cells

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19
Q

Extracellular Compartments

A

Refers to all fluid outside the cells (plasma, blood, interstitial fluids)

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20
Q

Intravascular Compartment

A

Fluids in the blood vessels (ECF subtype)

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21
Q

Interstitial Fluids

A

fluid between the cells and blood vessels

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22
Q

What compartment is the most important to view electrolyte levels from?

A

The intracellular compartments (ex: potassium is highest in the cell, not blood or ECF; almost no calcium in cells; small traces of Na, etc)

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23
Q

Most sodium is in …

A

the blood

(this is also the most sensitive electrolyte to the blood)

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24
Q

What does body fluid do for us?

A

Transports nutrients to the cells and carried waste products from the cells

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25
How much of the body weight is body fluids?
60%
26
What losses of body fluid are serious or fatal?
Serious - 10% Fatal 20% ex: 70 kg person has about (152 lbs) 42 L of body fluids (60%). 4.2 L 10%, and 20% is 8.4 L
27
How might body fluid amounts be different?
Older people usually have less fluid; Muscular people often have more So factors other than just loss is important like age and situation
28
Body fluid consists of what?
Water and dissolved substances
29
The largest single fluid constituent of the body is ..
water
30
Why is it important whether a substance dissolves or not in solution?
Some do not dissolve, glucose, urea, and creatinine, and therefore cannot be moved as simple substances Some larger ones do (ex: NaCl) and then their constituents can be moved easily
31
What is the ratio of ECF to ICF in the body
2/3 ICF to 1/3 ECF
32
Of extracellular fluid, what makes it up?
80% Interstitial Fluid 20% Plasma
33
How does body fluid differ between genders?
Males are 40% solid and 60% fluid, and Females are 45% solid and 55% fluids Women naturally have more body fat so they have less fluid, and fat does not hold water like muscle does
34
How does body fluid correlate to muscle and fat?
Increased fat = decreased total body water Increased muscles = increased total body water So, even if a person is heavier, they are at risk for dehydration
35
Diffusion
the movement of particles in all directions through a solution the process by which a solute may spread through a solution or solvent Goes from high to low concentration with little/no energy used
36
Solute
the substance that is dissolved
37
Solvent
the solution in which the solute is dissolved
38
When a solute diffuses how does it spread the molecules?
It spreads the molecules from an area of high concentration to an area of lower concentration (not a lot of energy to do this)
39
Permeable Membrane
a membrane allowing substances to pass through/diffuse without restriction we do not want these, we want some control
40
Selectively Permeable Membrane
membrane allowing some solutes to pass through without restriction but will prevent others from passing freely
41
Osmosis
Like a PULL of water or solvent across a membrane occurs when there is a more concentrated solution on one side of a selectively permeable membrane and a less concentrated solution on the other side - so osmotic pressure draws water through the membrane to the more concentrated side or the side with more solute
42
Water Osmosis occurs from ___ concentrated to ___ concentrated
low concentration to more concentration (in order to have equal concentrations on each side)
43
Osmotic Pressure
force that draws the water (pull) from less concentrated solution through a selectively permeable membrane into a more concentrated solution the difference determines strength
44
Hydrostatic Pressure
the force for filtration (PUSH pressure) - like water pushing against a water balloon the force exerted by the weight of a solution it moves from an area of greater pressure to an area of lesser pressure
45
Filtration
movement of solutes and solvents by hydrostatic pressure it moves from an area of greater pressure to an area of lesser pressure
46
Osmolality
refers to the number of osmotically active particles per kilogram of water
47
What unit is osmotic pressure measured in
Milliosmols
48
Normal osmolality of plasma is ...
280-294 mOsm/kg just a little less than 300
49
When there is a difference in hydrostatic pressure on two sides of a membrane, ___ and ___ ____ move out of the solution that has the ___ hydrostatic pressure by process of ____
When there is a difference in hydrostatic pressure on two sides of a membrane, water and diffusible solutes move out of solution that has the higher hydrostatic pressure by process of filtration
50
How does pressure differ at the arterial end of the capillary?
At the arterial end, hydrostatic pressure or push is greater than osmotic pressure - so more fluids and diffusible solutes move out of the capillary (via filtration)
51
How does pressure differ at the venous end of the capillary?
At the venous end, osmotic pressure or pull is greater than hydrostatic pressure - so fluids and some solutes move into the capillary (via osmosis)
52
What occurs to excess fluid and solutes remaining in interstitial spaces after osmosis and diffusion?
The excess fluid and solutes are returned to intravascular compartment by lymph channels
53
What separates interstitial fluid from intravascular fluid?
cell membranes (selectively permeable - may need energy like ATP with the NaK Pump)
54
The greater the number of particles in a concentrated fluid, the more ___ there will be to move ___ through the memvbrane
pull; water
55
Isotonic Solution
"Same" Solutions on both sides of the membrane have established equilibrium or are equal in concentration Equal tonicity - no shift in fluid Isotonic solutions have the same tonicity as body fluids
56
Tonicity
refers to concentration of dissolved molecules held in solutions isotonic solutions have same tonicity as body fluids and it occurs between the membranes this refers to being hypotonic, isotonic, and hypertonic
57
Examples of Isotonic Solutions
0.9% Sodium Chloride(Isotonic Saline / Normal Saline) - good for replacing fluid volumes 5% Dextrose 5% Dextrose in 0.225% Saline Lactated Ringer's Solution (for emergencies)
58
There is ___ to ___ mOs/kg in Normal Saline
280 to 294 (same osmolality as plasma)
59
What occurs for movement when an isotonic fluid is given?
little fluid movement / osmosis occurs
60
Hypotonic Solutions
When a solution has a lower concentration of salt than other solutions - it is hypotonic It has less salt OR more water than isotonic Fluid ends up moving into the cells Restores cells from dehydration
61
Examples of Hypotonic Solutions
0.45% Saline (dilutes blood by moving fluid into the cells - moves from a less concentrated to more concentrated) Distilled Water (no solutes)
62
What is the highest electrolyte in the blood
Salt
63
Hypertonic Solutions
A solution that has a higher concentration of solutes than another solution is a hypertonic solution
64
Examples of Hypertonic Solutions
10% dextrose in water 5% dextrose in 0.9% saline 5% dextrose in 0.45% saline 5% dextrose in lactated Ringer's Solution
65
What is the difference in hypotonic and hypertonic concentrations for blood and cells?
Hypotonic - fewer particles in blood, but more in the cell, so the cell gets water moving in and causes swelling (a problem) Hypertonic - more particles in the blood and fewer in the cells, so water moves out of cells to the blood - this dehydrates the cells
66
If the selectively permeable membrane will allow the solvent to pass through but will not allow the solute through freely...
the solvent will move to the side of greater solute concentration
67
If the extracellular fluid is 300 mOsm/kg in 17 L and inside the cell is 280 mOsm/kg in 25 L, what is the tonicity and changes after osmosis?
The ECF is hyperosmotic with ICF being Isotonic It will go from 300 in 17L in the ECF to 290 in 18 L; It will go from 280 in 25 L in the ICF to 290 in 24 L - this occurs because the water moves from inside the cell moves out to the higher concentration
68
If the ECF is 260 mOsm/kg in 19 L and ICF is 280 mOsm/kg in 25 L, what is the tonicity and changes after osmosis?
ECF is hypotonic with the inside of the cell being isotonic ECF goes 260 in 19 to 270 in 18 while ICF goes 280 in 25 to 270 in 26
69
Hypertonic solutions cause ___ while Hypotonic solutions cause ___
shrinkage ; swelling
70
Active Transport
moving an ion from low concentration to high concentration requires energy and active transport
71
Active transport moves molecules or ions ___ concentration and osmotic pressure
against
72
Energy for active transport is supplies by ___ ___ in the cell
metabolic processes (ex: ATP)
73
What are some substances that require active transport to move through the cell membranes
Na Ions, K ions, Ca, Iron, Hydrogen, some sugars, amino acids
74
What ways do fluids leave the body
Skin Lungs GI Tract Kidneys
75
The ___ excrete the largest quantity of fluid
kidneys
76
__ of urine can tell a lot about extra fluid amounts in the body
color
77
How much water is lost by the skin via diffusion per day?
300-400 mL per day
78
Water loss from perspiration depends on what?
depends on the temperature of the environment and of the body
79
Average amount of water lost via perspiration is ___ mL per day
100
80
How is water lost by the lungs and how can the amounts change?
lost via expired air which is saturated with water vapor amount varies with the rate and depth of respiration
81
Average amount of water lost from the lungs is ...
300-400 mL per day
82
Insensible Loss
water lost from lungs and skin that is lost without the person being aware of the loss You are unaware and cannot be measured
83
How does body fluid excretion relate to the GI tract
very large amounts of electrolyte containing liquids are secreted into the GI tract but almost all of this fluid is reabsorbed - and returns again to the ECF A LOT of it is reabsorbed
84
The average amount of water lost in the feces is ___ mL/day which is equal to ....
200 mL/day which is equal to the amount of water gained through oxidation of foods
85
How does severe diarrhea influence electrolyte and fluid balance?
loss of large quantities of fluids and electrolytes occurs
86
What organ plays a major role in regulating fluid and electrolyte balance?
Kidneys - they can adjust the amount of water and electrolytes leaving the body
87
What determines the quantity of fluid excreted by the kidneys?
determined by the amount of water ingested and the amount of waste and solutes excreted
88
Usual quantity of urine output is approximately ____; but this can vary greatly depending on ....
1500 mL per day Fluid Intake Amount of Perspiration Other Factors
89
Daily Body Fluid Excretion? Skin by Diffusion = __ Skin by Perspiration = __ Lungs = __ Feces = __ Kidneys = __ Total = __
Diffusion (Skin) - 350 mL Perspiration (Skin) - 100 mL Lungs - 350 mL Feces - 100 mL Kidneys - 1500 mL Total - 2400 mL / day
90
What are the three sources for water entering the body?
Oral Liquids Water in Foods Water formed formed by oxidation of foods (this includes tubes when doing I&O)
91
Average total amount of water taken into the body by the 3 sources of water is ___ mL per day
2400 mL/day
92
About how much water is released by metabolism of each 100 calories of fat, carbs, and proteins
10 mL
93
How are electrolytes replaced?
Electrolytes are present in foods and liquid and in a normal diet an excess of essential electrolytes is taken and the unused electrolytes are excreted via urine
94
Homeostasis
Balance a term which indicates the relative stability of the internal environment It is needed because concentration and composition of body fluids must be nearly constant
95
How is homeostasis directed in the deficiency and excess of electrolytes?
Deficiency - must replace fluids and electrolytes via either intake of food and water or by therapy like IV or meds Excessive - excess fluid or electrolytes needs therapy or diuretics directed toward assisting the body to eliminate the excess
96
Kidney role in maintaining fluid and electrolyte balance
play a major role in controlling all types of balance in fluid and electrolytes
97
Adrenal Glands role in maintaining fluid and electrolyte balance
it secretes aldosterone (direct sodium -retention- which water follows) it ends up aiding in controlling ECF volume by regulating the amount of sodium reabsorbed by the kidneys
98
ADH role in maintaining fluid and electrolyte balance
Antidiuretic hormone from pituitary gland regulates osmotic pressure of ECF by regulating amount of water reabsorbed by the kidneys
99
ADH and Aldosterone lead to ..
increased fluid volume (low flow states to the kidneys)
100
Factors that influence fluid intake
Climate activity level (like breathing faster using more fluid) social events emotions (binge or anorexia) LOC - confused/coma age-elderly (decreased sense of thirst, loss of taste buds, immobility, purposeful restriction, confusion and depression)
101
What are the total gains and loss of fluid in a day?
Gain = liquids 1100-1400 + solid foods 800-1000 + oxidation of CHO, proteins, fats 200-350 = 2500 mL/day Loss = respiration 300-400 + skin 300-400 + sweat 100 (1-2 L with exercise) + feces 100 + urine 1500 = 2500 mL/day
102
A lot of things are reabsorbed by the kidneys, but one thing that does not get reabsorbed is a good indicator of kidney function?
Creatinine (1.4 g)
103
_____ is a potent vasoconstrictor
Angiotensin II
104
What does aldosterone control?
salt which water then follows --> increased circulating volume
105
Pathway of the RAA system?
Renin release stimulated by low flow states to the kidneys and angiotensinogen works with it --> angiotensin I --> converted via enzyme to Angiotensin II --> Renal autoregulation, increased blood pressure, increased circulating volume
106
What gland releases Renin/RAA?
adrenal medulla
107
What gland releases ADH
posterior pituitary
108
What does ADH control?
governs water to increase fluid volume does this by telling kidneys to hold water and decrease osmolarity of plasma until it is right and gets negative feedback
109
ADH pathway?
increased plasma osmolarity or decreased circulating blood volume --> thirst --> increased fluid intake --> increased water retention increased plasma osmolarity or decreased circulating blood volume --> ADH secretion --> decreased water excretion --> increased water retention Increased water retention --> increased circulating fluid volume -> decreased plasma osmolarity --> decreased ADH and thirst
110
What things does decreased blood volume, increased serum osmolarity, and increased thirst and water intake lead to? (RAA and ADH)
stimulates ADH production in hypothalamus stimulate increased ADH release into the blood stream from posterior pituitary decreased arterial BP
111
What does a drop in arterial blood pressure lead to? (RAA and ADH)
increased sympathetic discharge --> decreased renal perfusion --> increased renin release --> angiotensin I and II --> increased aldosterone by the adrenal cortex --> drop in salt and H2O excretion and an increase in blood pressure increased sympathetic discharge --> decreased renal perfusion --> drop in water and salt filtered by the kidneys --> drop in salt and H2O excretion and an increase in blood pressure
112
What does a drop in salt and H2O secretion and an increase in blood pressure lead to? (RAA and ADH)
increased circulating volume of water and H2O with a loss of potassium --> increased blood volume and decreased serum osmolarity --> increased ADH production in hypothalamus
113
What does Increased ADH release into the blood stream from the posterior pituitary lead to? (RAA and ADH)
increased reabsorption of H2O by the kidneys --> decreased urine secretion -->increased circulating volume of water and H2O with a loss of potassium --> increased blood volume and decreased serum osmolarity --> increased ADH production in hypothalamus
114
The best way to measure daily fluid volume is ...
Daily Weight
115
Why can I&O be inaccurate?
it can be hard to get every bit of intake and output but it is a way to measure fluid weight / balance
116
Fluid Volume Deficit
dehydration in which water and electrolytes are lost in the same proportion
117
Goal of Fluid Volume Deficit treatment is to ...
goal of treatment is to restore fluid volume, replace electrolytes as needed, and eliminate the cause of the fluid volume deficit
118
Causes of Fluid Volume Deficit
vomiting diarrhea increased respiration use of diuretics and increased urine output insufficient IV fluid replacement GI suctioning draining fistulas ileostomy or colostomy drainage
119
How/things to/that assess fluid volume deficit?
increased respiration increased heart rate decreased central venous pressure (CVP) weight loss poor skin turgor dry mucous membranes decrease in urine volume urine is dark in color and odorous increased specific gravity of the urine increased hematocrit altered level of consciousness confusion
120
Things to Implement for Fluid Volume Deficit
Assess vital signs assess neck and hand vein turgor assess mucous membranes and skin turgor monitor hematocrit and electrolyte values replace fluids by PO or IV (lactated ringers solution, 0.9% normal saline) as prescribed administer medications as prescribed monitor weight daily monitor I&Os test urine for specific gravity monitor bowel sounds
121
Hypovolemia
Greater fluid loss than fluid intake
122
Isotonic Hypovolemia
this is Total Fluid Volume deficit water and lytes (Na+) lost in equal proportions ECF is iso-osmolar --> no change in ICF
123
Hypotonic Hypovolemia
decrease in solutes but not the water so, ECF is hypo-osmolar --> fluid shifts from ECF to ICF (in cell causes swelling)
124
Hypertonic Hypovolemia
decrease in water but not solutes ECF is hyper osmolar --> fluid shifts from ICF to ECF (shrinkage & dilute blood)
125
When talking about Hyper, Hypo, and Isotonic issues we are talking about ...
the BLOOD
126
Etiologies of Hypovolemia
GI Fluid Loss Kidneys Hyperosmolar Tube Feedings Fever Decreased Fluid Intake Skin Hemorrhage Third Spacing
127
What tonicity fluid hypovolemia does GI fluid loss get and examples of this loss?
Isotonic, Hypotonic Prolonged vomiting gastric suction excessive diarrhea
128
What tonicity fluid hypovolemia does Kidney loss get and examples of this loss?
Isotonic, Hypotonic Polyuria d/t DKA Renal Disease Diuresis
129
What tonicity fluid does hypovolemia due to fever loss get?
Hypertonic
130
What tonicity fluid does hypovolemia from decreased fluid intake get and examples of this loss?
Isotonic and Hypertonic Decreased LOC, sedation, NPO status Anorexia, N/V, Dysphagia Decreased Access, Depression
131
Examples of hypovolemic fluid loss from skin?
Excessive sweating burns
132
Why would we give isotonic and then hypotonic fluids to hypovolemics?
If there was loss from the GI or kidneys the isotonic can replace fluid volume and then the hypotonic solution moves fluid into the cells
133
Why would we give hypertonic solution to someone with a fever (hypovolemia)
Cells are getting more fluid than blood because of increased metabolic demand so this will bring fluid back into the blood
134
Why would we give isotonic and then hypertonic fluids ?
if they have decreased fluid intake the isotonic will correct circulating volume and then the hypertonic fluids prevent cell and brain swelling
135
Third Spacing
there is an appropriate amount of fluid in the body but it is stuck in the interstitial space between cells and the blood this can lead to hypovolemia
136
Why do we give isotonic fluids to third spacing?
it reestablishes circulating volume
137
What are some manifestations of Hypovolemia?
Rapid weight loss (1 L = 1 kg = 2 lbs; 1 lbs = 500 mL) Decreased skin turgor oral changes (dry membranes; longitudinal furrows on tongue) Decreased urinary output (oliguria <30 mL/hr or <400mL/24 hrs; increased urine specific gravity > 1.030) increased BUN (>10:1 BUN:Creat ratio) VS changes (decreased T, increased RR, orthostatic hypotension, increased FVD --> decreased BP in all positions) Decreased CVP (JVD) Decreased peripheral blood flow (>3 cap refill; cold extremities) increased thirst, HCT, confusion, weakness
138
BUN
nitrogen in the blood (urea) increase BUN indicates decreased renal function or dehydration (increased ratio is concerning)
139
How should solutions be taken in mild hypovolemia and severe hypovolemia?
Mild - Oral Intake Severe - IV Fluids
140
How should treatment go for Hypovolemia?
1. Isotonic Solutions (NS or LR) to re-expand plasma volume, increase BP, and possibly administer blood if d/t hemorrhage 2. Once normotensive, give a hypotonic solution (ex: 1/2 saline) to provide lytes and free water to make urine (ECF --> ICF)
141
Fluid Challenge
Something we do if we are unsure if the hypovolemia is due to a kidney problem or volume problem We give a bolus of water and if they do not increase urination then it may be a kidney problem, but good urinary output indicates dehydration.
142
Nursing Interventions for Hypovolemia
Measure I and O Daily Weight VS Skin BUN:Creat Ratio CVP PO Intake - oral care (consider tube feedings if cannot PO) Turn and Position - Moisturize Skin Evaluation of Adequate Fluid Replacement
143
What should be some signs of adequate fluid replacement from Hypovolemia?
increased urinary output (40-60 mL/hr) decreased urine specific gravity increased body weight T, BP, HR, RR normal skin turgor, oral moisture increased CVP increased sensorium and strength
144
Fluid Volume Excess
actual excess of total body fluid or a relative fluid excess in one or more fluid compartments also called Overhydration or Fluid Overload Hypervolemia
145
What is the goal of fluid volume excess treatment?
restore fluid balance, correct electrolyte balances, and eliminate or control the underlying cause of the overload
146
Difference between Peripheral Edema and Cellular Edema?
Peripheral Edema is ECF fluid excess leading to fluid between the cells Cellular Edema is ICF fluid excess leading to fluid in the cells
147
Hypervolumia
Fluid intake > Fluid loss
148
Isotonic Hypervolemia
water and lytes (Na+) gained in equal proportions ECF is iso-osmolar --> no change in ICF
149
Hypotonic Hypervolemia
Water intoxication increase in water but not solutes ECF is hypo-osmolar --> fluids shift ECF to ICF
150
Hypertonic Hypervolemia
Increase in solutes but not water ECF is hyper-osmolar --> fluid shifts ICF to ECF
151
Etiologies of Hypervolemia
Excessive intake of sodium and water either PO or IV Fluid retention d/t renal failure, SIADH (brain lesions can do this), cardiac disease (does not move water well), corticosteroid use (puffiness), cirrhosis of the liver, analgesic/anesthetic/psychotropic use
152
The Major cause of Hypervolemia is ...
Heart Disease
153
Manifestations of Hypervolemia
Rapid Weight Gain (5-7 pounds is severe) Circulatory Overload (Heart Failure) Interstitial Edema (peripheral edema (dependent) when legs are down; pulmonary edema (inspiratory fine crackles = minimum of 1500 cc) which can be life threatening JVD - distended neck veins Bounding pulse
154
Treatment for Hypervolemia
sodium restricted diet diuretics fluid restriction
155
Why would a sodium restricted diet be used for Hypervolemia?
if the hypervolemia is d/t HF, RF, liver disease, HTN (cautiously)
156
Loop Diuretic
lasix, bumex works on the loop of henle stronger diuretic
157
Thiazide Diuretic
HCTZ (not for HF or RF) not as strong as loop so its not for HF or RF
158
K Sparing Diuretic
Aldactone not as strong as loop or thiazide so not for HF or RF use either
159
Can diuretics fix everything for Hypervolemia?
no it could even reverse the problem to hypovolemia
160
What things can Diuretics cause?
FVD Hyponatremia Potassium Imbalances Loss of Mg Changes in Ca Excretion Acid Base Problems (Metabolic Acidosis)
161
Nursing interventions for Hypervolemia
I and O weight breath sounds edema in the feet, ankles, and sacrum lab value check (BUN and HCT) Rest (favors diuresis) response to diuretics IV fluids education on low sodium diet and self monitoring weight upright position for dyspnea turn and position
162
Hyponatremia
Serum sodium level <135-145 mEq/L d/t excessive sodium loss (without water) or excessive water gain (without sodium)
163
The most common electrolyte imbalance in a hospital setting is ..
hyponatremia with a 3% prevalence
164
Decreased Serum Osmolality in Hyponatremia leads to ...
First fluid moves from the ECF to ICF to cause swelling, and the second shift then cocurs where sodium shifts from ICF to ECF
165
Examples of electrolytes traveling together?
sodium and chloride potassium, calcium, magnesium
166
Most abundant lyte in the blood
Na+
167
Most abundant lyte in the cell
K+
168
Etiologies of Hyponatremia
Excessive Sodium Loss Insufficient Sodium Intake or Absorption Excessive Water Gain Adrenal Insufficiency SIADH
169
Excessive Sodium Loss examples that cause Hyponatremia
prolonged diuretic therapy burns excessive diaphoresis GI fluid loss: prolonged vomiting, NG suction, diarrhea, laxative abuse, repeated TWEs renal disease
170
Examples of things that lead to insufficient sodium intake or absorption leading to hyponatremia
anorexia acute alcoholism
171
Examples of things that lead to excessive water gain leading to hyponatremia
excessive administration of water PO or IV (D5W) psychiatric disorders with compulsive water drinking
172
How does adrenal insufficiency lead to hyponatremia?
low aldosterone compromises sodium reabsorption (and kidneys hold K instead)
173
How does SIADH lead to hyponatremia?
dilutional hyponatremia d/t water retention
174
Manifestations of Hyponatremia
Decreased Na+ I > O , decreased UO decreased urine specific gravity (<1.010) decreased Cl- (<100 mEq/L) decreased serum osmolality (<285) Weight gain - no significant edema Fingerprinting over sternum
175
What manifestations does decreased Na+ levels >125 lead to?
asymptomatic
176
What manifestations does decreased Na+ levels 120-125
nausea malaise abd cramps
177
What manifestations does decreased Na+ levels 115-120
headache lethargy obtunded
178
What manifestations does decreased Na+ levels <110-115
seizures coma personality changes
179
What is the hallmark of Hyponatremia?
Fingerprinting over the sternum ONLY hyponatremia causes this actual swelling of the cells, not in tissues or spaces, lead to this
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Cause and Effect of Hyponatremia
Causes: Excessive sodium loss or Sodium dilution with excess water Effects: Increased water in the brain, headache, weakness, lethargy, confusion, GI issues like not wanting to eat and diarrhea, plasma sodium low and urine gravity is low
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A lot of issues occur ____ for hyponatremia
neurologically (d/t cell swelling)
182
How to treat Hyponatremia
If its sodium loss: replace sodium PO or IV - NS for mild to moderate or 3% saline pump for severe (it is hypertonic so we dont wanna shift too fast from cells to circulatory system) (Na<120) For excessive water gain - restrict fluid intake
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Nursing Interventions of Hyponatremia
Restrict Fluids (teach family, fluid restriction, post sign) Accurate I and O (via IV pump) Daily Weight VS - BP and HR Neurologic Assessment (LOC, pupillary responses, muscle strength) Safety Precautions (side rails, seizures, precautions) Monitor lab values Turn and position
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The most important assessment for a hyponatremia patient is?
the Neurologic Assessment
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Hyponatremia has less salt in the blood, so where does fluid shift?
it will move into the cell which has higher salt concentration
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Hypernatremia
serum sodium level >145 mEq/L d/t excessive sodium gain (without water) or excessive water loss (without sodium)
187
What does the increased serum osmolality do for fluid shifting in hypernatremia?
fluid shifts from ICF to ECF (cellular shrinking) There is a higher concentration in the blood so it must be diluted
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Hypernatremia is most often a ___ problem
water problem never occurs in alert patients with normal thirst and access to water because of their thirst mechanism
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Etiologies for Hypernatremia
Water deprivation (i.e unconscious, debilitated, infants) Hypertonic Tube Feedings (without water supplements) Inadequately diluted baby formula High protein diets (without adequate fluids) Insensible water loss (i.e. burns hyperventilation or heat stroke) Watery Diarrhea Excessive administration of 3% saline (hypertonic) or sodium bicarb Diabetes insipidus (lack ADH - water loss without salt loss) Near drowning in sea water
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Manifestations of Hypernatremia
Dry Stick Mucous Membranes Neurologic (CNS) issues like hyperactive DTRs, disorientation, agitation with stimulation, hallucinations, lethargy --> Coma Neuromuscular issues like muscle twitching and convulsions Extreme thirst VS (increase T and HR, decreased BP) Oliguria and Anuria Lab values (increase Cl-, serum osmolality >295, urine specific gravity > 1.015)
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What are the hallmark symptoms of Hypernatremia?
Extreme Thirst Dry Sticky Mucous Membranes
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Cause and effects of Hypernatremia
Causes: Excess salt intake, Decreased salt loss, lack off sufficient water intake Effects: mucous membranes dry and sticky, intense thirst, tachycardia, agitation, restless - overall feelings hyper rather than lethargic
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Treatments for Hypernatremia
Slow correction -with 1/2 NS or 1/4 NS (hypotonic solution) to get water into cells (but not too fast like with D5W so there is no fluid overload or brain swelling) Drug Intervention - ADH, DDAVP, Thiazide Diuretics
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What is the paradoxical effect of thiazide diuretics for hypernatremia and diabetes insipidus?
it causes keeping water but getting rid of sodium
195
Hypernatremia Nursing Interventions
Identify Pts at Risk (i.e. hypertonic tube feeding or hypertonic TPN) Monitor I&O, VS, Mental Status, Daily Weight, Assess mucous membranes, monitor lab values, ensure adequate fluid intake teach about food salt contents, how to minimize salt intake, and salt restricted diets
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No less than how much salt should be given a day for renal patients and non-renal patients?
Renal - 1.5 g Non-renal - 2000g
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Hypokalemia
Serum potassium levels (low) < 3.5 mEq/L D/t excessive potassium excretion or inadequate potassium intake
198
Normal K+ levels in a person?
3.5 to 5.5
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K is greatest in what area? And by how much?
It is the major cation in ICF inside cells, and is 28x greater in the cell than outside it
200
Do we store excess K+?
no we get rid of excess with urine
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Etiologies for Hypokalemia
GI Losses (vomiting, diarrhea, suction, ileostomy, villous adenoma, alcoholism) Intracellular shifts (metabolic alkalosis, DKA) Anorexia Nervosa Dialysis treatment (excess removal) Excessive Insulin Renal losses (d/t hyperaldosteronism, nephrotic syndrome, diuretics, drugs, excess steroid release [Cushing's syndrome, excessive stress, tumors of adrenal cortex])
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K+ is essential for ...
the heart and GI system function
203
What typically regulates potassium?
The kidneys
204
Why does Metabolic Alkalosis lead to Hypokalemia?
It is a decreased H+ concentration - to correct this H+ moves from the cell to the blood and K+ moves into the cell to correct alkalosis to maintain neutrality If pH is above 7.45 this is metabolic alkalosis - low K+ in blood by correcting for H+ and moving into cells
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Manifestations of Hypokalemia
Decreased Serum Potassium Cardiac issues (Dysrhythmias, digitalis toxicity) Lab values (increased pH and bicarb, urine sg < 1.010, slight increase in serum glucose) Muscular weakness GI issues (anorexia, prolonged gastric emptying, gaseous distension, paralytic ileus) Renal Issues (inability to concentrate urine - dilute urine, polyuria - nocturia, polydipsia)
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Digitalis Toxicity
it is a medicine and if there is not enough K+ it can be toxic for the heart
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How does muscular weakness progress in Hypokalemia?
it progresses from the extremities inward
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Cause and Effects of Hypokalemia
Causes: Decreased K intake, Increased Loss of K, Shift of K into cells Effects: cardiovascular effects, kidney effects, muscle weakness
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Treatment for Hypokalemia
IV replacement (never give K in any form if there is no kidney function - there needs to be urine output before giving K) (never IV push K as it can lead to cardiac arrest) (mix thoroughly and it is an irritant) Dietary (foods and salt substitutes) Oral Supplements (administer w/ meals to decrease GI irritation, give with full glass of water, contraindicated if on K sparing diuretic)
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When is potassium oral supplements contraindicated?
When on a K Sparing Diuretic Or with bad kidney function
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Why must you never pump more than 10 mEq/hr or in 100 mL over 1 hour with a pump for potassium?
It is IV pushing and can lead to arrythmias and potential cardiac arrest
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Hypokalemia Nursing Interventions
Prevention for Pts at risk Monitor I and O Cardiac Monitoring Adminsiter Potassium Supplements VS (HR, BP) Monitor Lab Values (for alkalosis) Teaching on dietary intake, salt supplements, and supplements to take with food
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What are some foods high in potassium
apricots bananas oranges carrots baked potatoes with skin
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How do you know kidney function is good enough for K treatment?
they have good urine output
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Hyperkalemia
Serum Potassium levels > 5.0 mEq/L d/t excessive potassium intake or impaired potassium excretion
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Hyperkalemia seldom occurs in what situations?
In patients with normal kidney function
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What is the most common reason for Hyperkalemia?
Often due to iatrogenic causes and more common in hospitalized older adults SO, its more common WHEN WE CAUSE IT
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What is more dangerous, hyperkalemia or hypokalemia
Hyperkalemia due to a higher risk for lethal arrhythmia (more likely to get dysrhythmia in hypokalemia)
219
Etiologies for Hyperkalemia
Decreased Renal Excretion Hypoaldosteronism (not holding enough Na and its leaving in urine and you have more K) K Sparing Diuretics (block hypoaldosteronism) Drugs (trimethoprim, NSAIDS, ACE inhibitors, B adrenergic drugs, cyclosporine) Metabolic Acidosis Tissue injury and lysis of cells (28x more in cells so release is bad) Excessive oral or IV intake (use of potassium containing salt substitutes in RF) Bowel obstruction
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Manifestations of Hyperkalemia
Cardiac Issues (high lethal arrhythmia issues; cardiac arrest; bradycardia) CNS - confusion Neuromuscular (muscle weakness, flaccidity, paresthesia, numbness, ascending paralysis from LEs) GI (Nausea, intermittent colic, diarrhea) Oliguria
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What EKG changes occur from Hyperkalemia?
Depressed ST Segment Peaked T Waves Widened QRS Complex Prolonged PR Interval Loss of P Waves
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What does ST Segment depression mean
ST segment does not return to isoelectric line - so ischemia occurs (hyperkalemia)
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What does Peaked T Waves mean
K sets the resting membrane potential so we get peaked T waves - which is abnormal (hyperkalemia)
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What does Widened QRS complex mean
signals have trouble going through the ventricle (hyperkalemia)
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What are the major manifestations of Hyperkalemia?
Cardiac Arrhythmias leading to cardiac arrest and bradycardia and CNS confusion
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How does metabolic acidosis lead to Hyperkalemia?
The body corrects acidosis (<7.35) by moving H+ into cells which moves K+ out into the blood all comes from buffer system for pH
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What symptoms are in both hypo and hyperkalemia and therefore cannot tell you which it is alone?
Neuromuscular manifestations
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How does activity differ between Hyper and Hypokalemia?
Hyperactive - Hyperkalemia Hypoactive - Hypokalemia
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Cause and Effect of Hyperkalemia
Cause: Excess intake, decreased loss, shift of K out of cells Effects: Cardiac issues, muscle problems, GI vomiting/nausea, renal oliguria --> anuria, confusion
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Treatment for Hyperkalemia
Kayexalata PO or PR (Cation Exchange Resin) IV Diuretics (if renal functioning properly) Dialysis
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Kayexalate
cation exchange resin must be used cautiously when person has HF must either take by mouth and excrete it in 24 hours with diarrheal stool or take a retention enema for 30-60 minutes with an indwelling cath
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Emergency Treatments for Hyperkalemia
Calcium Gluconate Sodium Bicarbonate GIK Mechanism (Insulin)
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Calcium Gluconate
slow IV infusion protective mechanism for the heart - it increases the threshold to make sure the heart does not fire as quickly, but it does not get rid of potassium
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What is the mechanism of action for Calcium Gluconate
decreased K lowers resting membrane potential and increased K raises it Ca++ raises the threshold to correct the difference from potassium the difference is what usually causes arrhythmia
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How does sodium bicarbonate help treat Hyperkalemia?
it moves K into cells temporarily - could be life saving
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How does GIK treat Hyperkalemia?
Insulin moves BOTH K and Glc into cells - temporarily but a quick fix Normal glc levels means give both insulin and glucose to remove K
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Nursing Interventions for Hyperkalemia?
Prevention for pts at risk Monitor I and O Cardiac Monitoring Administer K depleting meds VS watching (HR and BP) Monitor lab values (acidosis) Assess bowel function Teach about renal failure and insufficiency, foods high in potassium, salt substitutes, and not using K sparing diuretics Proper venipuncture technique (false potassium increases occur d/t cell lysis)
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Pseudohyperkalemia
false potassium increase from cell lysis from improper venipuncture technique
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EKG differences between Hypokalemia and Hyperkalemia
Hypo - flat T wave; Hyper - peak T wave Both have depressed ST Segment Hyper has prolonged PR interval potentially
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What is the EKG changes that signifies Hyperkalemia more so than others?
A peak T Wave
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What charge is Calcium ions
2+
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Hypocalcemia
Serum Calcium Level <8.5 mg/dL d/t inadequate calcium intake or absorption, or excessive calcium excretion or elimination
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99% of Ca2_ is stored in ..
bones and teeth as calcium phosphate (so when it is released both phosphate and calcium release)
244
Narrow calcium range in the blood ?
8.5 to 10.5 (since most is in bones or teeth)
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What happens with PTH when Ca2+ levels drop
PTH pulls from bones: so decreased Ca2+ causes increased PTH
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You can end up with weak brittle bones if there's PTH too much because Parathyroid ___
pulls!
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What is needed to absorb calcium?
Vitamin D
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Why can loss of renal function lead to Hypocalcemia
we need the kidney to activate Vitamin D in order to absorb calcium
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How does Celiac disease influence Hypocalcemia?
it is a malabsorption problem that impacts the serum calcium levels
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How does calcium travel in the blood?
Calcium travels the blood freely in a metabolically active form that is ionized 50% of this is unbound calcium 50% is a form of calcium bound the plasma proteins
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___ calcium + ___ calcium = Total Serum Calcium Levels
Bound + Unbound = Total
252
How does Total Calcium change and symptoms occur depending on how bound and unbound levels of calcium change?
If both levels lower, total calcium lowers If plasma proteins are loss and there's less bound calcium, but there is still unbound calcium present you also get lower total levels, BUT you will not get s/s if you have normal unbound ranges (ionized) However, if things move from unbound to bound to correct imbalance, that wont be reflected in total Ca, so we do need to look at more to know Serum Calcium Levels
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What things may decreased bound calcium levels?
some with decreased protein intakes, nursing home residents, or liver disease get hypoalbuminemia and decreased plasma proteins --> decreased bound calcium with normal unbound still the same --> total calcium decrease but not S/S
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The body regulates via __ calcium
unbound calcium bound is not metabolically active since its on proteins, only when unbound is high or low does hyper or hypocalcemia occur
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If protein or albumin levels are low you can infer what?
That bound calcium levels are low, especially is there is no s/s
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What form of calcium is more informative ?
Unbound/Ionized calcium
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S/S of Hypocalcemia and Hypercalcemia only occur when ...
unbound calcium is low and total calcium lowers as a result
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A balance between what things allows for calcium homeostasis?
absorption from the gut, excretion from the kidney, and reabsorption or deposition from bone
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What cascade of actions fix low calcium levels?
Hypocalcemia --> PTH pulls calcium from bones, tells kidney to increase calcium reabsorption/activate Vitamin/excrete more PO4 3+, increases calcium uptake in GI tract
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What is the most important step of the bodies natural attempt to fix hypocalcemia?
Activation of Vitamin D, after the Kidneys get PTH, which leads to increased calcium uptake by GI
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Etiologies of Hypocalcemia
Post Op (Parathyroidectomy, thyroidectomy, radial neck dissection) Renal Failure (d/t hyperphosphatemia) Alkalosis (citrated blood) Acute Pancreatitis Drugs Inadequate intake or absorption (anorexia, chrons, vit D deficiency, lack of sun exposure, etc) Excessive elimination (low PTH levels d/t hypomagnesemia s/t alcoholism or diuretics) Hypoalbuminemia
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Manifestations of Hypocalcemia
Neuromuscular (Calcium sets resting membrane potential so low amounts lead to firing sooners) - so muscular irritability, tingling, parathesias, cramps, spasms, tetany, seizure, positive chvostek and trousseau sign, hyperactive DTR. CNS - confusion, anxiety, depression, psychosis, loss of sensorium Cardiovascular - decreased Myocardial contractility, hypotension, dysrhythmia, EKG prolonged QT and ST Hematologic - prolonged PT, PTT, bleeding and bruising (no calcium for the clotting cascade) *Overall irritability, hyperactivity, no clotting, low heart power, depressed CNS*
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Trousseau's Sign
Sign for Latent Tetany (spasm) You pump 20 mmGHg above normal systolic, and if there is hypocalcemia leave it a minute and the patient will end up having a carpopedal spasm (arm twitch down) It is a sign of neuromuscular irritability along with Chvostek's sign
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Chvostek's Sign
Sign for latent tetany (spasm) Tap facial nerve, and the lip on that side of the face will twitch It is a sign of neuromuscular irritability along with Trousseau's Sign
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Cause and Effect of Hypocalcemia
Cause Decreased unbound calcium, inadequate intake, excess loss, decrease in GI tract and bone absorption Effect: CNS issues, Cardiovascular system dysrhythmia (weak heart ability), increase GI tract irritability, abnormal calcium deposits, muscle tetany!
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Acute Hypocalcemia Treatment
Calcium gluconate via slow IV infusion Need to monitor as calcium in the tissue can cause necrosis! Do not give with Digoxin The CaGlc cn prevent laryngospasm and protect the heart and life threatening spasm
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Chronic Hypocalcemia Treatment
Oral Calcium Supplements w/ Vit D an Mg HRT - estrogen replacement, soy Calcitonin (prevention in osteoporosis) Fosamax (inhibits bone resorption)
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Whys is Fosamax a nasty drug?
must take upright take firs tin the morning must be taken on an empty stomach with water only very nasty drug
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Nursing Interventions for Hypocalcemia
Prevention for pt at risk Administer calcium supplements calcium gluconate at bedside for thyroid/neck surgery Cardiac monitoring Maintain airway patency Monitor lab values Seizure/Safety Precautions (if severe) teach about alcohol and cig influence, dietary sources, exercise (weight bearing exercise), estrogen
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Dietary Sources of Calcium
Dairy Products Green Leafy Vegetables
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Hypercalcemia
Serum calcium levels > 10.5 mg dL Acute > 13 mg/dL Severe >16 mg/dL d/t excessive calcium intake or absorption; or; increased release of calcium from bone Occurs when the rate of calcium entry into the ECF . rate of renal calcium excretion
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Etiologies of Hypercalcemia
Excessive Intake of calcium supplements Excessive use of calcium containing antacids Excessive vitamin D intake (stims absorption) Use of thiazide diuretics Hyperparathyroidism (or tumor makes too much PTH pulling lots of calcium from bones) Prolonged immobility malignancies drug thyrotoxicosis hypophosphatemia (means less exchange of calcium at kidney level) milk alkali syndrome
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Milk alkali Syndrome
ingest sodium bicarbonate and get calcium from milk, they then combine to form extra calcium in the bloodstream
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Manifestations of Hypercalcemia
Neuromuscular (sedate effect, weakness, decreased DTRs) GI (decreased motility, constipation(ca is chalky), anorexia, N/V) CNS (confusion, memory impairment, bizarre behavior, decrease in LOC--> Coma) - decreased innervation leads to decreased nerve speed Renal (polyuria, polydipsia, renal colic, renal failure from urinary calculi) Cardiac (dysrhythmia, EKG shortened QT, increased BP) Bone (soft tissue calcification, pathologic fractures)
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Why does polyuria and polydipsia occur with Hypercalcemia?
Glucose AND calcium increases tonicity of urine - so filtrate absorbs more fluid and polyuria occurs, with polydipsia since there is less fluid and you want to replace it
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Cause and Effect of Hypercalcemia
cause: loss from bones, excess intake, increase from factors increasing mobilization from bones effect: cardiovascular system, bradycardia, dysrhythmia, kidney issues GI issues, muscle issues (EVERYTHING SLOWS DOWN MORE)
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Treatment for Hypercalcemia
High Fluid intake (3-4 L / day) Eliminating contributing drugs (thiazides, vitamin D, calcium antacids) Increase mobility IV NS 200-500 mL/Hr to dilute calcium and increase GFR and loop diuretic prevents overload and increases excretion Hourly I and O and breath sounds Etidronate, Plicamycin, Calcitonin
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When is Etidronate (Didronel) used for Hypercalcemia
tx for malignancies that are NOT hyperparathyroidism
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When is Plicamycin (Mithracin) used for Hypercalcemia
tx for breath cancer
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How is Calcitonin used to treat Hypercalcitonin
skin test first it decreases bone resorption by stopping PTH to protect bones and ionized calcium levels temp effect of 6-10 days so you need to target the root cause still
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Nursing Interventions for Hypercalcemia
Prevention for Pts at risk Increased mobility Monitor I and O 3-4 L of fluid per day Bulk fiber in diet to decrease constipation Safety Precautions Check for pathological fractures and digoxin toxicity Encourage cranberry juice to increase calcium solubility in urine Calcitonin Monitor lab values Teach about s/s to watch for and avoid dairy products and calcium containing antacids
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How is calcium balance regulated when calcium levels get high
Decreased PTH and Increased Calcitonin --> (d/t PTH) decreased renal activation of Vit D) --> DECREASED intestinal absorption of calcium, renal reabsorption of calcium and decreased excretion of phosphate, and calcium resorption from bone
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How is calcium balance regulated when calcium levels get lower
Increased PTH and Decreased Calcitonin --> (d/t PTH) Increased renal activation of Vit D --> INCREASED intestinal absorption of calcium, renal reabsorption of calcium and decreased excretion of phosphate, and calcium resorption from bone
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EKG differences between Hypocalcemia and Hypercalcemia ?
Hypo - prolonged ST segment and QT interval Hyper - shortened ST segment and QT interval
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Second most abundant cation in the cell behind potassium?
Magnesium
286
Percentages of Magnesium Cation distribution?
60% in bones 2% in ECF 38% in interstitial spaces
287
Normal Magnesium levels
MG 1.5-2.3 mEq/L or 1.8 - 2.6 mg/dL
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Sources of magnesium
unprocessed cereal grains nuts chocolate legumes green leafy vegetables dairy products dried fruit meat fish water not processed through a water softener
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Hypomagnesemia
A decreased serum Mg level of less than 1.5 mEq/L or 1.8 mg/dL
290
Serum does not reflect ___!
Stores!
291
Causes for hypomagnesemia
decreased Mg intake excessive loss of calcium and potassium vomiting diarrhea NG suction GI losses Intestinal malabsorption Intestinal Fistulas increased renal excretion prolonged diuretic therapy excessive aminoglycoside use rapid administration of citrated blood renal disease chronic alcoholism diabetic ketoacidosis burns pancreatitis
292
Why does calcium and potassium loss lead to hypomagnesemia?
Magnesium moves with Potassium and Calcium together so loss of one leads to loss of the others
293
Why does GI loss lead to hypomagnesemia so easily
There is a lot of Mg in the lower GI tract and intestinal absorption determines this so malabsorption here can lead to hypomagnesemia
294
The biggest causes of hypomagnesemia are...
malabsorption intestinal fistula (things that impact GI tract (lower))
295
Why does rapid citrated blood administration lead to hypomagnesemia
the preservative turns your blood alkalotic so buffer systems move things causing this
296
What can be sued to treated hypomagnesemia from alcoholism
folate and multivitamins
297
S/S of Hypomagnesemia
CNS - convulsions, paresthesia's, tremor, ataxia Mental changes - agitation, depression, confusion Cardiovascular System- tachycardia, dysrhythmia Muscle - cramps, spasticity, tetany, athetoid movement, BABINSKI REFLEX, CHVOSTEK SIGN Neurologic irritability- tetany, weakness EKG - broad T wae, ST shortened, Prolonged QT interval, and wide QRS complex - severe can invert T waves and prominent U waves Laryngeal Stridor, coma, or sudden death if severe
298
Why is babinski reflex abnormal in hypomagnsemia?
it usually is gone by an early age
299
Implementation to care for Hypomagnesemia
Monitor VS, neuromuscular changes, I and Os Initiate seizure precaution Administer oral or IV magnesium Monitor Ca2+ and K+ levels and administer both if levels are low as prescribed Monitor for DTR suggesting hypermag when administering Monitor serum Mg levels every 12-24 hours when client is receiving Mg by IV Instruct client to eat food high in Mg Ca2+ and K+
300
Hypermagnesemia
increased magnesium serum levels of 2.3 mEq/L or 2.6 mg/dL
301
Causes of Hypermagnesemia
Advanced renal failure excessive laxative use that contains magnesium overuse of antacids (that have Mg) ECF fluid deficit (concentrated with Mg) Administration of Mg in toxemia of pregnancy Untreated acute diabetic ketoacidosis Hemodialysis w/ hard water or dialysate too high in Mg Adrenal insufficiency Pheochromocytoma (rare)
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Most common cause of Hypermagnesemia
Advanced Renal Failure
303
S/S of Hypermagnesemia
Neurologic Depression - Slowing Down Drowsiness Lethargy Bradycardia Dysrhythmias ECG shows peak T wave, prolonged PR and QT intervals, wide QRS Respiratory Depression Paralysis of resp center and voluntary muscles severe hypotension along w/ nausea and vomiting muscle weakness areflexia loss of DTR coma
304
Hypermagnesemia looks like ___ and ___
death and hypercalcemia
305
Areflexia
no reflexes at all - dangerous
306
Implementations for Hypermagnesemia Patients?
Monitor VS, Resp. Depression, hypotension, bradycardia, and dysrhythmias, neuro and muscular activity, LOC remove source of excess Mg increase renal excretion by forcing fluids or administering diuretics administer 10% calcium gluconate as prescribed mechanical ventilation in severe Mg excess pacemaker for bradycardia dialysis if renal function is impaired with Mg free dialysate instruct clients regarding avoiding the use of laxatives and antacids containing Mg
307
Calcium Glouconate protects the ___ and ___s Mg
protects the heart and antagonizes Mg
308
EKG differences between Hypomagnesemia and Hypermagnesemia?
Hyper - wide QRS, prolonged PR, Tall T wave Hypo - Prolonged QT, slightly longer PR, widened QRS, Flat T waves / broad flat T wave, prominent U wave
309
What is in Hypomagnesemia's unique EKG finding
Prominent U Wave
310
Phosphorus Normal Values
3-4.5 mg/dL or 1.8-2.6 mEq/L
311
What is a major anion in cells (negative charge)?
Phosphorus
312
How is phosphorus distributed in the body?
85% of phosphorus in bones and teeth less than 1% in blood rest in soft tissue
313
What is phosphorus responsible for
proper mineralization of bone and for energy metabolism - and is a part of ADP and ATP
314
Sources of Phosphorus
Almonds Dried Beans Barley Bran Pumpkin Squash Cheese Cocoa Chocolate Eggs Lentils Meats Poultry Pork Beef Legumes Fish Sardines Liver Milk Oatmeal Peanuts Dried Peas Walnuts Wheat and Rye Soft Drinks
315
What kind of soft drink has more phosphorus?
darker color soft drinks - so renal patients that hold Phosphorus should not drink these
316
Hypophosphatemia
serum phosphorus level below 3 mg/dL or below 1.8 mEq/L below normal serum level
317
Most phosphorus is absorbed in the ___ and excreted via the ___
phosphorus; kidneys
318
Causes of Hypophosphatemia
Decreased Nutritional Intake Poor Absorption from the bowel due to a lack of Vitamin D Intake of carbonate antacids (may hinder absorption) Malabsorption Syndrome Increased renal excretion due to hyperparathyroidism or renal insufficiency Diabetic Ketoacidosis Steatorrhea A poor nutritional state as in alcoholism Fever Long term TPN Burns Hepatic Disease
319
What is Phosphorus relationship to Calcium
they are inverse so if you get rid of Calcium you keep Phosphorus and vice versa via level of kidneys
320
Steatorrhea
fat in stools floats very smelly
321
S/S in assessment of Hypophosphatemia
Anorexia Dysphagia Weakness Malaise, Lethargy Skeletal Pain and Aches Bone Pain Pathologic Fractures Pulmonary Fractures Tachypnea Shallow Respiration Confusion, Stupor, Delirium Seizures Hematologic Changes Need Phosphorus for ATP so you have less energy!!!! (A LOT OF THESE ARE SIMILAR TO HYPERCALCEMIA)
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If hypophosphatemia is occurring, what else is happening?
Hypercalcemia (so many s/s are similar)
323
Implementations for Hypophosphatemia
Monitor respiratory status Move client carefully Administer potassium phosphate Assess renal system before administering phosphorus Monitor calcium, phosphorus, sodium, and chloride levels - renal failure DOES hold Phosphorus Administer vitamin D Monitor for decreased neuromuscular activity Monitor for calcium excess and kidney stones Monitor for hematologic changes Monitor clients receiving TPN for electrolyte imbalances Instruct client regarding the use of antacids
324
When do kidney stones occur?
when calcium is exchanges and phosphorus leaves - so damage can occur
325
Hyperphosphatemia
A serum phosphate level greater than 4.5 mg/dL or 2.6 mEq/L Seen more clinically then hypophosphatemia
326
Causes of Hyperphosphatemia
Excessive dietary intake of phosphorus Overuse of phosphate containing laxatives or enemas Hypoparathyroidism Vitamin D intoxication (more vit D - more absorption) Renal failure Adrenal insufficiency Excessive bone growth in infants and children (cows milk has more phosphorus than breast milk) Metabolic and hormonal imbalances Tissue damage Parathyroid Surgery or Hypoparathyroidism
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S/S seen in Assessment for Hyperphosphatemia
Neurological Excitability Hyperreflexia, tetany Positive Chvostek's or Trousseau's Sign Seizures Conjunctivitis Pruritis Renal Deposits leading to renal failure Opp of hypophosphatemia - looks like hypocalcemia
328
Hyperphosphatemia goes alongside ___
hypocalcemia (since they exchange)
329
What is seen more clinically, hyperphosphatemia and hypophosphatemia?
Hyperphosphatemia
330
Pruritis
itching
331
How does hyperphosphatemia instigate further renal failure?
Renal deposits occur from increased phosphorus that leads to deposits in renal tissue binding with calcium thus stimulating further renal failure
332
Implementation of Nursing Interventions for Hyperphosphatemia
Increase fecal excretion of phosphorus by binding phosphorus from food in the GI tract (aluminum hydroxide gel) Prepare for dialysis if prescribed Administering calcium if hypocalcemia exists Monitor neuromuscular irritability Monitor for hyperreflexia, tetany, and seizures Monitor for signs of hypocalcemia Monitor for Trousseau’s and Chvostek’s signs Instruct clients to avoid phosphate-containing medications including laxatives and enemas Instruct clients to decrease their intake of foods high in phosphorus Instruct clients how to take phosphate-binding drugs emphasizing that they should be taken with meals or immediately after meals